Nursing Elites

1. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

• A. Crackles in the lungs
• B. Shortness of breath
• C. Elevated liver enzymes
• D. Heart rate of 100 beats per minute

Correct answer: C

Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.

2. A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?

• A. Decreased bowel sounds
• B. Increased heart rate
• C. Decreased urine output
• D. Elevated blood glucose level

Correct answer: C

Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.

3. A client with type 1 diabetes is admitted with hypoglycemia. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push
• B. Administer 15 grams of oral glucose
• C. Recheck the blood glucose level in 15 minutes
• D. Administer a glucagon injection

Correct answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating hypoglycemia to rapidly increase blood glucose levels. This choice is correct because in severe cases of hypoglycemia, when a client is admitted and unconscious or unable to swallow, intravenous administration of dextrose is crucial to quickly raise blood glucose levels. Option B, administering 15 grams of oral glucose, would be suitable for conscious clients with mild hypoglycemia who can swallow safely. Option C, rechecking blood glucose levels, should follow after immediate intervention to assess the response. Option D, administering a glucagon injection, is more suitable for cases where dextrose is not readily available or when the client does not respond to dextrose administration.

4. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?

• A. Maintain the client NPO during the diuresis phase.
• B. Evaluate daily serial renal laboratory studies for progressive elevations.
• C. Observe the urine character for sedimentation and cloudy appearance.
• D. Monitor for the onset of polyuria greater than 150 ml/hour.

Correct answer: B

Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.

5. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Blindness due to cataracts
• B. Acute kidney injury due to glomerular damage
• C. Stroke secondary to hemorrhage
• D. Heart block due to myocardial damage

Correct answer: C

Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.

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